Basic Information
| Provider Information | |||||||||
| NPI: | 1053413443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDY | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDY-CHARLES | ||||||||
| OtherFirstName: | DIANNE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2950 CLEVELAND CLINIC BLVD | ||||||||
| Address2: | SUITE # A11/12 | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333313609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546595144 | ||||||||
| FaxNumber: | 9546596192 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 CLEVELAND CLINIC BLVD | ||||||||
| Address2: | SUITE # A11/12 | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333313609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546595144 | ||||||||
| FaxNumber: | 9546596192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 35-070238 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 2307042 | 05 | OH | MEDICAID |